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Clinical Challenges in Otolaryngology
October 2004

Considerations in Subcondylar Fracture Management

Author Affiliations
 

KAREN H.CALHOUNMD

 

RONALD B.KUPPERSMITHMD

Arch Otolaryngol Head Neck Surg. 2004;130(10):1231-1232. doi:10.1001/archotol.130.10.1231

Perhaps no area of facial trauma has inspired more controversy than the management of mandibular subcondylar fractures. Fractures of the condylar region occur frequently, representing more than 30% of all mandible fractures, and they have been treated with either closed or open reduction techniques, and with similar outcomes.13 Proponents of each technique cite the advantages and disadvantages of one over the other. For example, the "open" surgeons claim better anatomic reduction and postoperative radiographic appearance, while the "closed" surgeons favor a conservative approach with potentially fewer surgical complications and acceptable long-term functional results. Although certain factors have been proposed as relative and/or absolute indications for an open approach,4 an individual determination must be made in each case. In general, the treatment algorithm is based on patient age, unilateral vs bilateral subcondylar fractures, presence of associated fractures, axial inclination of the condylar head (>35°), level of fracture in the ramus, intracapsular head fractures, dislocation of the condyle from the confines of the glenoid fossa, vertical shortening (>5 mm) of ramus height (condylion to gonion), severe pain, masticatory function, range of mandibular motion, significant jaw deviation/deflection upon opening, malocclusion, difficulty in achieving maximum intercuspation of the teeth, and patient preference after consideration of the uncommon risks associated with an open approach (eg, nerve injury and facial scar). The criteria for success following treatment of mandibular subcondylar fractures include reestablishment of premorbid occlusion, pain-free range of motion (>35-40 mm), adequate jaw excursions/protrusion, facial symmetry, minimal facial scar and facial nerve injury, and/or prolonged limitation of mouth opening. Once the decision has been made that the fracture fulfills the criteria for an open approach, the decision tree branches once again to include the recent addition of endoscopic guidance during fracture reduction and stabilization. During the past decade, surgeons became intrigued with the concept of minimally invasive surgery to avoid the patient morbidity that could arise from more traditional open surgical techniques (eg, laparoscopic techniques). While it is against surgical dicta to consider treatment of traumatic injuries through small incisions and limited access, the application of minimally invasive surgery to facial fracture repair has become widespread.5 Surgeons must decide whether any new technique offers significant advantages over conventional techniques to warrant its use in clinical practice based on published evidence-based results. Endoscopic fracture repair has been described as an approach to fracture management with a potential for decreased patient morbidity. Some types of fractures may be more amenable to endoscopic assistance than others, including lateral override fractures, low-level subcondylar/ramus fractures, minimal delay in treatment (<24-48 hours), full dentition (for posterior support of intraoperative intermaxillary fixation), and noncomminuted fractures. Since the surgical techniques and technology, as well as the indications, continue to develop, there are few data in the literature regarding the outcomes of endoscopic fracture treatment.612 The major limitation to the use of endoscopy is the additional training required and the learning curve issues that accompany any new technique. It is expected that the initial operative times may be longer than with traditional open subcondylar fracture surgery; however, similar operative times will be obtained after the first interventions, and the advantages and usefulness of the technique will then become apparent. Long-term outcomes of endoscopic-assisted repair of subcondylar fractures are similar to those obtained with open and closed approaches, but the intraoperative benefits of improved visibility in an illuminated and magnified field of view, decreased bleeding, and better anatomic reduction, as well as expected decreased postoperative patient morbidity (eg, pain, edema, and limitation of opening), make endoscopy an attractive surgical adjunct.

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